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Mike Boucher

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What Else The Radiologist Must Report!

The diagnosis is pretty straightforward in this case for most of the radiologists and radiology residents. The kidneys are symmetrically enlarged with multiple cysts with a few cysts in the visualized liver as well. The radiology features are consistent with Autosomal Dominant Polycystic Kidney (ADPKD). But is diagnosis enough in this case? Is this the reason why the referring clinician has sent the patient? Read on to find out. An essay writer is a person whose job is to create articles and this important topic will also be highlighted in an essay format.

Role of Imaging in ADPKD:

Ultrasound:

  • Modality of choice for screening.
  • Diagnostic criteria (Ravine criteria modified by Pei et al. ) for patients WITH FAMILY HISTORY.
Ultrasound-based Ravine’s criteria for diagnosis of Autosomal Polycystic Kidneys
  • In children less than 15 years of age, even a single cyst is diagnostic.
  • Absence of cysts in patients more than 40 years rules out ADPKD.  
  • Ultrasound screening is recommended at 20-30 years of age, as the sensitivity is lower for patients in the younger age group.
  • Typical cysts are seen as anechoic structures with posterior acoustic enhancement. Hemorrhage into cysts can produce a heterogeneous appearance. In patients with an acute presentation, it is important to assess perinephric fat as often hemorrhage can elicit an inflammatory response in the adjacent fat which is causing the patient’s symptom. A potential pitfall of ultrasound is that it can be difficult to differentiate infection from hemorrhage. 

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CT and MRI:

  • Not required for diagnosis in most cases.
  • Ultrasound has poor sensitivity for cysts less than one-centimeter in size in infants. In these cases, T2W MRI can be used as a screening tool.
  • Although renal cell carcinomas (RCC) have been reported, there is no proven association with ADPKD.
  • Why patients present in the emergency setting:
    • Nephrolithiasis: Non-contrast CT.
    • Complex cysts (Hemorrhage or infection): CT with contrast or MRI.

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Imaging to assess disease severity and progression in ADPKD:

  • Total kidney volume (TKV) plays a major role in the prognosis of the disease and is the GOLD standard image biomarker for early ADPKD progression.
  • Renal cysts are formed in uteri and grow with age. Up to a certain extent the renal function is preserved but in the latter phases, the cysts compress the renal parenchyma and renal insufficiency sets in. Have a look at the serial images of a patient with ADPKD a few years apart. There is progressive thinning of normal renal parenchyma on the image on the right.

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Conclusion:

  • Ultrasound is the screening modality of choice for ADPKD.
  • CT/ MRI can be used for problem solving and evaluation of complicated cysts.
  • It is important to offer screening ultrasound to offsprings and siblings of patients.
  • Total kidney volume is the GOLD standard image biomarker for early ADPKD progression and can be calculated on non contrast CT by using ellipsoid formula. A height-corrected total kidney volume (htTKV) of 600 ml/m predicts the future development of CKD stage 3 within 8 years.